Stroke: Pathophysiology, Symptoms, and Nursing Interventions

Stroke Overview

• Stroke involves identifying, explaining pathophysiology, clinical signs and symptoms, complications and medications
• Understand nursing diagnoses, interventions and necessary patient teaching related to strokes

Ischemic Stroke Characteristics

• Pathophysiology involves a blood clot that blocks an artery supplying blood to the brain, depriving brain tissue of oxygen and nutrients, ultimately leading to ischemia and infarction
• Common causes of strokes include atherosclerosis, A-fib and subsequent blood clots, high blood pressure, diabetes, high cholesterol, smoking, obesity, substance abuse (cocaine or excessive alcohol), and oral contraceptive use in women

Recognizing Stroke Symptoms and Potential Complications

• Common signs and symptoms of a stroke may include sudden numbness/weakness on one side, facial drooping, slurred speech, confusion, severe headache, dizziness, and loss of balance/coordination
• Resulting complications may include brain damage, paralysis, speech/language problems, memory loss, emotional problems, pneumonia and deep vein thrombosis

Treatments and Nursing Interventions for Strokes

• Medications may include anticoagulants like warfarin and heparin, antiplatelets like aspirin and clopidogrel and thrombolytics like alteplase to dissolve clots
• Nursing diagnoses identified may be impaired physical mobility, risk for aspiration, acute pain, risk for falls and self-care deficit

Addressing Stroke Intervention and Patient Teaching

• Interventions can include frequent neurological status assessment, maintaining airway, administering medications, helping with ADLs, preventing complications and rehab collaboration
• Patient teaching should include stroke risk factors, medication management, lifestyle adjustments (diet, exercise, smoking cessation), rehabilitation exercises, recognizing warning signs, and available community resources

Thrombotic Stroke Explained

• Pathophysiology involves a blood clot (thrombus) forming locally in a brain-supplying artery, blocking blood flow and potentially stemming from atherosclerosis, high blood pressure, or artery wall trauma
• Stroke signs and symptoms may include sudden numbness/weakness on one side of the body, facial drooping, slurred speech, confusion, severe headache, dizziness, and loss of balance/coordination

Implications of Thrombotic Stroke Complications, Medications, and Nursing care

• Complications may include brain tissue damage, paralysis, speech/language problems, memory issues, emotional disturbances, pneumonia, and deep vein thrombosis
• Medication options are anticoagulants (warfarin, heparin), antiplatelets (aspirin, clopidogrel) and thrombolytics (alteplase) to dissolve clots

Managing Thrombotic Stroke and Patient Education

• Nursing diagnoses frequently include impaired physical mobility, risk of aspiration, acute pain, risk of falls, and self-care deficit
• Interventions should include frequent neurological assessments, airway management, medication administration, help with ADLs, preventing complications, and stroke team collaboration

Hemorrhagic Stroke Explained

• Stroke pathophysiology involves blood vessel rupture, causing bleeding in or around the brain, as with intracerebral or subarachnoid hemorrhage
• Common causes may be hypertension, aneurysms, arteriovenous malformations, and trauma to the head

Recognizing and Addressing Hemorrhagic Stroke

• Signs and symptoms include sudden severe headache, nausea/vomiting, altered mental status, seizures, numbness/weakness, vision changes, and neck stiffness
• Resulting complications include brain damage, herniation, hydrocephalus and increased intracranial pressure

Hemorrhagic Stroke: Medication, Nursing, and Teaching Strategies

• Medication options include antihypertensives to control blood pressure, anticonvulsants for seizures, and osmotics to reduce intracranial pressure
• Nursing diagnoses focus on the risk for increased intracranial pressure, acute pain, risk for seizures, and impaired physical mobility

Risk Factors of Strokes

• Stroke may result from hypertension (high BP), diabetes, A-fib, heart disease, coronary heart disease, atherosclerosis, hyperlipidemia (high cholesterol), blood disorders and autoimmune diseases
• Risk also increases due to previous stroke/TIA

Modifiable and Non-Modifiable Risk Factors of Stroke

• Modifiable risk factors may include smoking, excessive alcohol consumption illicit drug use (cocaine), poor diet/obesity, physical inactivity and uncontrolled hypertension/diabetes, high cholesterol levels
• Non-modifiable risk factors may include hypertension, high BP, DM, hyperlipidemia, high cholesterol, A-fib, increasing age, family history of stroke or cardiovascular disease, gender, race, or prior stroke/TIA

Understanding TIA versus Stroke

• TIA: Transient ischemic attacks are defined by brief, temporary blockage of blood flow, usually lasting less than 5 minutes and up to 24 hours
• With TIA the brain experiences brief lack of oxygen/nutrients, leading to temporary neurological symptoms like weakness, numbness, vision problems, or speech difficulties. TIA does not cause permanent brain damage but requires treatment as it is a stroke warning sign

Stroke Causes and Neurological Deficits

• Stroke is defined by more prolonged blockage or bleeding in the brain, leading to permanent brain damage and the death of brain cells
• Strokes can cause lasting neurological deficits that depend on the area of the brain affected

Brain Hemispheres and Strokes

• The left hemisphere controls language (speech, writing, comprehension in Broca's and Wernicke's areas)
• The left brain is responsible for logical thinking, analytical skills and mathematics

Right Brain Hemispheres and Stroke

• The right hemisphere governs motor skills on the right side of the body and processes visual-spatial information and visual imagery
• The right hemisphere interprets patterns, faces, and nonverbal cues, controls creativity, intuition, emotional expression, and artistic abilities, and governs motor skills on the left side of the body

Aphasia Information

• Aphasia is an acquired language disorder that impairs communication and affects the production/comprehension of speech and the ability to read/write
• The condition typically stems from damage/injury to the left hemisphere, with the type and severity dependent on the damage location and extent

Different Forms of Aphasia Following Stroke

• Broca's aphasia is classified as expressive or non-fluent speech involving difficulty producing speech from the frontal area
• Patients understand but cannot communicate verbally and their speech is labored and halting, with grammatical errors and omissions

Forms of Aphasia Continued

• Wernicke's aphasia (temporoparietal area), is receptive or fluent, resulting in impaired language comprehension
• Speech is fluent but lacks meaning, using nonsensical words/sentences, and the patient cannot understand spoken/written words

Mixed and Global Aphasia

• Global or mixed aphasia has impairment in all language modalities, language dysfunction occurring in expressive and receptive aphasia
• Aphasia does not affect intelligence, but can significantly impact a person's communication abilities

Communication Strategies for Aphasia

• Nursing interventions for aphasia may include repetitive directions, breaking tasks into steps, repeating names of objects and allowing extra time for communication
• Picture boards and computer devices can be use to help the patient

Identifying Left-Side Stroke Symptoms

• The left hemisphere controls language, speech production, comprehension, and motor function on the right side of the body
• Stroke signs and symptoms can present as aphasia (difficulty speaking, understanding, reading, or writing), apraxia (inability to perform purposeful movements), right sided weakness and paralysis, right visual field deficits, impaired analytical thinking and problem-solving skills and difficulty with mathematics.

Stroke - Logical Sequencing and Right Side Deficits

• Right sided deficits can develop from impairments with logical sequencing
• The right hemisphere controls visual-spatial processing, attention to the left side, awareness of deficits and aspects of behavior and personality

Stroke - Right Sided Symptoms

• Symptoms of right side stroke may include left sided weakness or paralysis, impaired visual-spatial abilities and perception, difficulty recognizing faces or objects and problems with depth perception and navigating spaces
• Lack of awareness of deficits (anosognosia), impulsive behavior and poor judgement, difficulty interpreting nonverbal cues/body language, potential for flat affect and emotional lability and memory deficits can also result

Elderly Stroke Risk Factors

• Elderly face an increased prevalence of risk factors like hypertension, diabetes, atrial fibrillation and hyperlipidemia, which in turn lead to clots or plaque buildup in arteries.
• These strokes can also be attributed to atherosclerosis and stiffening of blood vessels, which can lead to blockages and reduced blood flow to the brain.

Elderly Stroke

• Elderly strokes can result from weakening of the heart muscle over time, reducing its ability to pump blood effectively as well as a great likelihood of having had previous transient ischemic attacks (TIAs)
• Physiological changes in the cardiovascular system, like reduced exercise capacity, increases stroke risk. Also, potential for falls/trauma causes bleeding (hemorrhagic stroke).

Communicating with Stroke Patients

• Communication options include communication boards with letters or words and pictures as well as mechanical voice synthesizers. In addition, computers and mobile devices can be used.

Diagnostic Timeline for Stroke

• Stroke diagnostic studies should be done within 3 hours
• Obtain a non-contrast CT scan or MRI of the brain to rule out a hemorrhagic stroke, and identify the location and extent of the blocked blood vessel causing the ischemic stroke

Glasgow Scale/ NIHSS

• Note the stroke type and site prior to administering alteplase (tPA), a clot-busting medication, only given within 3-4.5 hours of symptom onset for eligible ischemic stroke patients
• Prompt neuroimaging is essential for proper stroke management and improving potential patient outcomes

Glasgow Coma Scale (GCS)

• A neurological assessment tool to evaluate a patient's consciousness by scoring eye opening, verbal response, and motor response that can range from 3 to 15 (3 indicating a comatose state and 15 being fully alert and oriented)
• Lower scores signify more severe neurological impairment

NIHSS with Stroke

• The National Institutes of Health Stroke Scale (NIHSS) assesses neurological deficits
• Evaluated areas include level of consciousness, vision, facial palsy, motor strength, sensation, language, and neglect. Scores range from 0-42 with higher scores indicating more severe impairment from stroke

Stroke - Treatment Trajectory

• The NIHSS helps determine eligibility for acute stroke treatments and to track changes over time
• Assess the stroke patient’s level of function and any deficits, assist with bathing and feeding, assist with dressing (beginning with weaker/affected side first), position and support affected limbs properly and perform range of motion exercises to maintain mobility.

Stroke Safety and Diet

• Focus on implementing fall precautions and adhering to dietary restrictions if dysphagia is present
• Antiplatelets drugs like Aspirin/Clopidogrel, prevent clot formation in stroke or heart disease; can lead to bleeding and stomach ulcers. Note contraindications of active bleeding or severe liver/kidney disease.

Lab Test for Medications

• Laboratory tests should measure platelet count, liver/kidney function, assess for bleeding and monitor platelets
• Anticoagulant medications prevent/treat blood clots; include risks like bleeding, bruising and anemia.

Anticoagulation

• Anticoagulation contraindications may be active bleeding and severe liver/kidney disease
• Note lab tests of PT/INR/aPTT monitoring
• Focus on bleeding precautions, antidote availability and diet education. Patient teaching should promote compliance, activity precautions and bleeding management

Thrombolytic Medications

• Thrombolytic medications like Alteplase, dissolve clots in acute ischemic stroke/MI, with side effects like bleeding and cerebral hemorrhage
• Note contraindications like active bleeding/recent surgery
• Lab tests can include coagulation studies and platelet count and intervention requires frequent neuro and vital checks. Educate on risks and benefits

Post Stroke Anti-Hypertensive

• AntiHypertensives medications are used to control high BP post-stroke; side effects are dizziness, fatigue and cough. Note contraindications like renal artery stenosis and pregnancy
• Monitor BP, fluid status, medication adherence and low-salt diet

Recognizing Intracranial pressure

• It's important to monitor for signs of increased intracranial pressure: severe headache, nausea/vomiting, altered mental status, pupillary changes/vision disturbances, neurological deficits, seizures, decreased consciousness progressing to coma and an irregular breathing pattern should be noted
• Note purposes of endovascular nursing interventions to provide comprehensive catheter-based procedures to treat vascular conditions

Managing Stroke with Nursing Diagnoses

• Focus nursing diagnosis on Impaired Physical Mobility for hemiparesis or hemiplegia by positioning and assisting with ambulation
• Other nursing diagnoses may be Impaired Swallowing by involving swallowing assessments, dietary modifications and aspiration as well as the risk for falls, and emphasize bed alarms and close supervision

Pain Relief from Strokes

• You can treat acute pain related to muscle spasticity and headaches through pharmacological methods and positioning
• Note the risk for Impaired Verbal Communication through alternative communication methods

Providing Stroke-Related care

• Focus on anxiety related to life changes through emotional support, counseling, and coping strategies while addressing deficient knowledge regarding disease process, medications, and provide patient/caregiver education
• Unilateral neglect calls for positioning affected side, cues, and occupational therapy

Care with Dysphagia

• Dysphagia refers to difficulty swallowing that results from stroke or neurological conditions
• Increase the risk of aspiration as liquid or secretions enter the airways
• Signs and Symptoms consist of choking, wet voice, or food pocketing in cheeks with treatment consisting of thickened liquids and close monitoring

Ensuring Stroke Recovery

• Promote fall precautions, skin maintenance, and environmental safety
• Encourage consistent monitoring and closely observe for neurological changes. Closely observe neurological status, vital signs, intake/output, and any changes to promptly intervene if complications arise. As the same time provide stroke education and discuss rehabilitation goals

Stroke Medications and Patient Safety

• Medication management reviews new prescriptions and dosages, and addresses medical adherence
• Prevent any complications, home or otherwise

Alzheimer’s disease

• Alzheimer’s disease pathophysiology involves elevated abnormal proteins in the brain: extracellular amyloid plaques disrupting inflammatory responses and intracellular neurofibrillary tangles eventually leading to cell death.
• Risk factors are age, genetics, down syndrome, and head trauma

Alzheimer's diagnostic tests

• These tests support a diagnosis through: Amyloid PET scan for protein buildup, MRI to show atrophy, CSF to measure biomarkers, genetic testing and cognitive assessment
• Treatment and interventions includes a structured environment, activities and wandering safeguard protocols

Stages of Alzheimer’s disease

• Stages are: early/mild, forgetfulness, misplacing items, subtle changes and independence. Middle/moderate includes orientation, money issues, psychosis, and memory loss. Late/severe calls for full ADLS
• Management is mainly through cholinesterase inhibitors to improve symptoms, side effects consist of fatigue, dizziness, headache, constipation, hypertension with monitoring of cognitive functions

Aducanumab usage

• Aducanumab helps treat AD by reducing the amyloid beta plaques with side effects including brain swelling, confusion, dizziness, headaches; regular MRI scans are used to monitoring this
• Home education may include safety, community resources, diet, and relaxation

Dementia

• Dementia is mainly diagnosed through a medical exam and neuro/psycholocal testing
• Blood and imaging tests may find a stroke like pathology

Dementia types and causes

• Dementia results from different etiology, be it tumors or disease. Symptoms consist of memory loss over time; and not delirium which is rapid impairment
• Care consists of a calming environment and clear communication

Stages of Dementia

• Stages also mirror Alzheimer’s with: Early includes getting lost, middle with behavioural issues, and late becoming difficult to the touch

Medications for Dementia

• Treatment consists of monitoring Cholinesterase inhibitors like: donepezil.
• Side effects include: nausea, vomiting, insomnia. Encourage families and recommend for a good quality of life

Delirium and Diagnostics

• Delirium stems from illness and trauma impacting neurotransmitters for memory or emotion; it is often marked by sudden confusion and disconnectedness.
• Diagnoses are based on disturbances over short periods of time

Care with Delirium

• It is important to find the etiological cause for it as a nurse. Provide for a calming environment and reorient the environment

Diabetes and the Types

• Diabetes is made up of Type 1 and Type 2 versions
• Diabetes I involves the immune system attacking the pancreas that causes absolute insulin deficiency. It is caused idiopathic issues
• Diabetes II involves a progressive disorder caused by the person having insulin resistance.

Elderly vs Younger DM

• Aging adults can develop DM due to beta decline in the pancreas and insulin decreasing. Accumulation of all these factors can lead to diabetes.
• There are multiple complications: heart attacks, retinopathy, kidney failure, and skin conditions

Diabetic Diagnosis

• For diabetes patients, the recommended blood glucose ranges are: 74-106 mg/dL and <180mg/dL post meal
• A1C: Less than 7% for most non-pregnant adults and continuous glucose monitoring (CGM), the target is to maintain glucose levels within the range of 70-180 mg/dL for at least 70% of the time
• Blood sugar is normal between 70-130 and low when around 55-70 or 4-55 mg/dL

High Blood Sugar

• High blood sugar is 140-399 mg/dL with a dangerous value being under 500mg/dL
• Comorbidities: Cardiovascular Disease, kidney failure, risk of infections

Diabetic ulcers

• These ulcers form due to peripheral neuropathy and foot deformities; make sure to check feet. Provide regular inspections, proper footwear, total contact casts, wound debridement
• Early signs of hypo: hunger, shakiness, and dizziness. Late symptoms such as confusion and irritability. Hyper include: thirst, urination, blurred vision

Diabetes

• Fasting Plasma and Hemoglobin Levels are tested for; high levels can equal inaccuracy
• You can encourage diets and check A1C, blood pressure, foot exams, and lifestyle modifications. There is also Somogyi effect that stems from high blood sugar from eating dinner

Hypo vs Hyper

• Hypoglycemia results from too much insulin and occurs in mornings. Managed through dietary intake. Dawn phenomenon consist of raising sugars throughout
• Regular activity helps. Sick day=monitoring blood flow, skin and neuro assessment

Insulin action

• Give at 3-4 glucose tabs with follow ups of 15 minutes
• Act as an insulin and provides instructions of food/fluids, monitoring and sugar levels

Understanding Diabetes

• Diabetes is a hormone regulated by blood sugars, therefore encourage protein synthesis, increased potassium and anabolic effects
• With diabetes stems problems of Lipodystrophy (abnormal fat) due to side effects

Types of Insulin

• Rapid Acting consists of 0 minutes of onset with 1-3 duration
• Regular insulin = 30min, 2.4 duration. Intermediate/ NPH equals 1-3 onset with 10-16 duration

Long Acting Insulin

• Long acting has 24 hour duration and no peak. Metformin is the first line of treatment. It can cause N/V/D and lead to lactic acidosis
• The lab values are blood, creatinine, with frequent administration. Report GI issues and monitor diet

Glipizide treatments

• Glipizide takes 30 minutes before meals; this can lead to high weight or Nausea
• Note that Glucagon-like peptide can improve glycemic levels

Administering Insulin

• Insulins of Regular (short) and NPH must have a check 2x before; rotating after infection site
• There may be interactions with ginseng and cinnamon; therefore, make sure no to intake! Normal glucose rates consist of values greater than 500 and less than 54 mg

Treating Diabetes

• Management is through diet and medications with a focus on complex carbohydrate intake of 45-60%
• Nursing wise, make sure to monitor levels and prevent complications while encouraging adherence

Diabetic wounds

• Assess: size, depth, drainage to prevent trauma and edema
• Nursing wise keep a consistent blood glucose rate and provide education on the patient plan

Epilepsy Primary vs Secondary

• Seizures results from metabolic disorders and genetic predispositions. While low sleep, fatigue or environmental stimuli lower seizure threshold
• You may notice sudden excessive discharge of electricity and neurons within the brian

Common Seizure Types

• With generalized seizures, there is tonic (stiffening) in body. petit (loss of awareness); while partial consist of loss of smell
• Amnesia- results from brain problems that involve traumatic trauma or psychological events with varying times

Risk Factors and Triggers

• This can be affected by the brain, and there are a number of factors! Alcohol, injury all lowers seizure threshold
• Nursing is to prepare the padded side rails by clearing equipment to assist oxygen wise. Call for support to maintain precautions

Stages and phases for Seizures

• Prodlomal and early-ictal phases occur before as patients experience nausea and irritability phases
• Time and support from family is essential

Responsibilities of a nurse for Seizures

• Responsibilities are timing, observations while maintaining patent and documenting activity
• Note if there restrain, breathing and skin

Questions to note with family

• “How did the seizure last” or note any activity
• Medication wise, watch Phenytoin. Report drowsiness and osteoporosis. With Valporic, be aware of hairloss

Safe therapeutic interventions

• Interactions with carbamazepine include antiacids decreasing actions, and report any abnormal sensations
• For safety wise, remove stimuli and be open-minded with family on these issues.

Drug Sensitivities

• For a seizure prone patient, avoid alcohol and photosensitive activities
• Levetiracetam needs to be monitored with behavioral health and for function. However, do not use any drugs

Surgical treatment

• You may need medications to resolve issues or surgery for stimulation in surgery. Remember you must check vitals pre and post surgery and make sure to report complications!

Hypothyroidism Pathophysiology

• Pathophysiology may involve a deficiency in thyroid hormones (T3 and T4) due to production with autoimmune destruction. This can lead to tumors in bodies
• There will be a decline in the metabolism! Make sure to reduce dosing with age

Important Assessments and Actions

• Make sure that the dose is at a low dose with proper assessment and intervention with other medications
• Assess for fatigue and weight gain while supporting family function

Thyroid Exams and Function

• Thyroid Function is assessed with the enlargement or swelling within the neck while assessing swelling
• Low levels of thyroid equal high TSH and high T =LOW TSH

Treatment options

• Levothyroxine is a treatment route you cannot miss. Watch weight and heart rates while also managing stress
• You may develop myxedema (skin changes) resulting from poorly managed processes and lethargy

Hyper vs Hypo Symptoms

• Hyper is: heat, irritation to skin
• Hypo is: Fatigue and low hair

Graves' disease vs Thyroid Crisis

• Graves results in rapid function;
• nursing actions involve managing support and anxiety to calm their storm. Thyroid crisis results from poor and unmanaged effects that lead to CV collapses

Triggers and Treatments

• Triggers are usually stemming from stress in surgery
• The treatment consists of monitoring medications with IV and oxygen and fluids all around

Pre and Post-Operation considerations

• Pre operation preparation and testing with a thyroidectomy will provide assistance
• There may be laryngeal damage! Watch surgical sites and monitor vitals. This also includes Hashimoto's where the immune system destorys the TH levels